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RTOG 0920 - A PHASE III STUDY OF POSTOPERATIVE RADIATION THERAPY (IMRT) +/- CETUXIMAB FOR LOCALLY-ADVANCED RESECTED HEAD AND NECK CANCER

Description

OBJECTIVES: Primary - Determine whether the addition of cetuximab to postoperative intensity-modulated radiotherapy (IMRT) will improve overall survival (OS) in patients with locally advanced squamous cell carcinoma of the head and neck at intermediate risk following surgery. Secondary - Assess the impact of the addition of cetuximab to postoperative IMRT on disease-free survival (DFS) of these patients. - Assess the impact of the addition of cetuximab to postoperative IMRT on acute and late dysphagia, xerostomia, skin toxicity, and other toxicities according to common Toxicity Criteria for Adverse Effects (CTCAE), v. 4 and their relationships with patient-reported outcomes at 3, 12, and 24 months. - Analyze tumor for epidermal growth factor receptor (EGFR), specifically the extent of EGFR overexpression by immuno-histochemistry (IHC) and FISH analysis, EGFRvIII expression, as well as the association of these assay data with OS and DFS. - Analyze tumor for human papillomavirus (HPV) infection (as defined by in situ hybridization), specifically, within the cohort of patients with oropharynx cancer, to perform an exploratory analysis of the impact of HPV on DFS and OS of this patient subset. - Analyze tumor DNA for TP53 mutations as a predictor of response to cetuximab and prognosis. - Analyze germline DNA of polymorphic variants in EGFR intron repeats as a predictor of response to cetuximab. Tertiary - Assess the impact of the addition of cetuximab to postoperative IMRT on loco-regional control. - Assess the impact of the addition of cetuximab to postoperative IMRT on patient-reported quality of life, swallowing, xerostomia, and skin toxicity based on head and neck specific instruments, including the Performance Status Scale for Head and Neck Cancer (PSS-HN), the Functional Assessment of Cancer Therapy-Head & Neck (FACT-H&N), the University of Michigan Xerostomia-Related Quality of Life Scale (XeQOLS), and the Dermatology Life Quality Index (DLQI). - Assess the impact of the addition of cetuximab to postoperative IMRT on cost-utility analysis using the EuroQol (EQ-5D). - Evaluate the utility of image-guided radiotherapy (IGRT) as a means of enhancing the efficacy (i.e., loco-regional control) of IMRT while reducing the acute and/or late toxicity (particularly xerostomia) and improving patient-reported outcomes (particularly XeQOLS scores). - Retrospectively compare the loco-regional control rate in patients treated with IMRT alone (no IGRT or cetuximab) with similar patients treated with external beam radiotherapy alone in the postoperative clinical trial Radiation Therapy Oncology Group (RTOG)-95 01. OUTLINE: This is a multicenter study. Patients are stratified according to clinical stage (T2-3 vs T4a), EGFR expression (high [≥ 80% of cells staining positive] vs low [< 80% of cells staining positive] vs not evaluable), primary site of disease (oral cavity vs larynx vs oropharynx p16+ vs oropharynx p16- vs oropharynx, p16 not evaluable), and use of image-guided radiotherapy (yes vs no). Patients are randomized to 1 of 2 treatment arms. - Arm I: Patients undergo intensity-modulated radiotherapy (IMRT) once daily 5 days a week for 6 weeks in the absence of disease progression or unacceptable toxicity. - Arm II: Patients undergo IMRT as in arm I. Patients also receive cetuximab IV over 1-2 hours once weekly beginning at least 5 days prior to the start of IMRT and continuing for 4 weeks after the completion of IMRT (for a total of 11 doses) in the absence of disease progression or unacceptable toxicity. Quality of life is assessed at baseline and at 3, 12, and 24 months. Tissue samples are collected periodically for further laboratory analysis. After completion of study treatment, patients are followed up at 1 and 3 months, every 3 months for 2 years, every 6 months for 3 years, and then annually thereafter.

Phase

Phase 3 - a treatment has shown activity against a particular disease, where it is either added to existing treatment or compared to the standard treatment.

Inclusion and Exclusion Criteria

  • Histologically confirmed squamous cell carcinoma (including variants, such as verrucous carcinoma, spindle cell carcinoma, or carcinoma not otherwise specified) of the head and neck, including the following subtypes:
  • Oral cavity
  • Oropharynx
  • Larynx
  • Clinical stage T1, N1-2, M0 OR T2-4a, N0-2, M0 disease based on the following diagnostic workup within the past 8 weeks:
  • General history and physical examination by a Radiation Oncologist and/or Medical Oncologist
  • Chest x-ray or chest CT scan (with or without contrast) or chest CT/PET scan (with or without contrast)
  • Must have undergone gross total resection of the primary tumor with curative intent within the past 7 weeks with surgical pathology demonstrating ≥ 1 of the following criteria for "intermediate" risk of recurrence:
  • Perineural invasion
  • Lymphovascular invasion
  • Single lymph node > 3 cm or ≥ 2 lymph nodes (all < 6 cm) (no extracapsular extension)
  • Close margin(s) of resection, defined as cancer extending to within 5 mm of a surgical margin, and/or an initially focally positive margin that is subsequently superseded by intraoperative negative margins (similarly, patients whose tumors had focally positive margins in the main specimen but negative margins from re-excised samples in the region of the positive margin are eligible)
  • Pathologically confirmed T3 or T4a primary tumor
  • T2 oral cavity cancer with > 5 mm depth of invasion
  • No positive margin(s) (defined as tumor present at the cut or inked edge of the tumor), nodal extracapsular extension, and/or gross residual disease after surgery PATIENT CHARACTERISTICS:
  • Zubrod performance status 0-1
  • Absolute granulocyte count ≥ 1,500/mm³
  • Platelet count ≥ 100,000/mm³
  • Hemoglobin ≥ 8.0 g/dL (transfusion or other intervention allowed)
  • Total bilirubin < 2 times upper limit of normal (ULN)
  • Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) < 3 times ULN
  • Serum creatinine < 2 times ULN OR creatinine clearance ≥ 50 mL/min
  • Not pregnant or nursing
  • Negative pregnancy test
  • Fertile patients must use effective contraception
  • No other invasive malignancy within the past 3 years, except for nonmelanomatous skin cancer or previously treated carcinoma in situ of the breast, oral cavity, or cervix
  • No simultaneous primary or bilateral tumors
  • No severe, active co-morbidity, including any of the following:
  • Unstable angina and/or congestive heart failure requiring hospitalization within the past 6 months
  • Transmural myocardial infarction within the past 6 months
  • Acute bacterial or fungal infection requiring IV antibiotics at the time of study registration
  • Chronic obstructive pulmonary disease exacerbation or other respiratory illness requiring hospitalization or precluding study therapy
  • Idiopathic pulmonary fibrosis or other severe interstitial lung disease that requires oxygen therapy or is thought to have required oxygen therapy within the past year
  • Hepatic insufficiency resulting in clinical jaundice and/or coagulation defects
  • AIDS based on current Centers for Disease Control (CDC) definition
  • Grade 3-4 electrolyte abnormalities according to CTCAE, v. 4, including any of the following:
  • Serum calcium (ionized or adjusted for albumin) < 7 mg/dL or > 12.5 mg/dL*
  • Glucose < 40 mg/dL or > 250 mg/dL
  • Magnesium < 0.9 mg/dL or > 3 mg/dL*
  • Potassium < 3.0 mmol/L or > 6 mmol/L*
  • Sodium < 130 mmol/L or > 155 mmol/L* NOTE: *Despite intervention to normalize levels.
  • No prior allergic reaction to cetuximab PRIOR CONCURRENT THERAPY:
  • See Disease Characteristics
  • No prior systemic chemotherapy or anti-epidermal growth factor (EGF) therapy for this cancer
  • Prior chemotherapy or anti-EGF therapy for a different cancer allowed
  • No prior radiotherapy to the region of the study cancer that would result in overlap of radiotherapy fields
  • No concurrent amifostine as a radioprotector
  • No concurrent granulocyte colony-stimulating factor or erythropoietin

Sites

  • California

    • University of Southern California/Norris Cancer Center, Los Angeles, California, 90033
    • Los Angeles County-USC Medical Center, Los Angeles, California, 90033
    • Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, 90027
    • Pomona Valley Hospital Medical Center, Pomona, California, 91767
    • UC San Diego Moores Cancer Center, LA Jolla, California, 92093
    • Memorial Medical Center, Modesto, California, 95355
    • Kaiser Permanente Medical Center - Santa Clara, Santa Clara, California, 95051
    • Stanford University Hospitals and Clinics, Stanford, California, 94305
    • Bay Area Tumor Institute CCOP, Oakland, California, 94609
    • UCSF-Mount Zion, San Francisco, California, 94115
    • Sutter Cancer Centers Radiation Oncology Services-Cameron Park, Cameron Park, California, 95682
    • University of California at Davis Cancer Center, Sacramento, California, 95817
    • Mercy General Hospital Radiation Oncology Center, Sacramento, California, 95819
    • Mercy San Juan Medical Center, Carmichael, California, 95608
    • Sutter General Hospital, Sacramento, California, 95816
    • Sutter Cancer Centers Radiation Oncology Services-Vacaville, Vacaville, California, 95687
    • Radiological Associates of Sacramento, Sacramento, California, 95815
    • Sutter Cancer Centers Radiation Oncology Services-Roseville, Roseville, California, 95661
    • The Permanente Medical Group-Roseville Radiation Oncology, Roseville, California, 95678
    • Sutter Cancer Centers Radiation Oncology Services-Auburn, Auburn, California, 95603
    • Saint Helena Hospital, Saint Helena, California, 94574
  • Utah

    • Dixie Medical Center Regional Cancer Center, Saint George, Utah, 84770
    • Intermountain Medical Center, Murray, Utah, 84157
    • Utah Cancer Specialists-Salt Lake City, Salt Lake City, Utah, 84106
    • LDS Hospital, Salt Lake City, Utah, 84143
    • Huntsman Cancer Institute/University of Utah, Salt Lake City, Utah, 84112
  • Nevada

    • Renown Regional Medical Center, Reno, Nevada, 89502
  • Arizona

    • Arizona Oncology Associates-West Orange Grove, Tucson, Arizona, 85704
  • New Mexico

    • University of New Mexico, Albuquerque, New Mexico, 87106
  • Idaho

    • Saint Alphonsus Regional Medical Center, Boise, Idaho, 83706
  • Oregon

    • Willamette Valley Cancer Center, Eugene, Oregon, 97401
    • Salem Hospital, Salem, Oregon, 97301
    • Clackamas Radiation Oncology Center, Clackamas, Oregon, 97015
    • Oregon Health and Science University, Portland, Oregon, 97239
    • Portland Veterans Administration Medical Center, Portland, Oregon, 97239
    • Providence Saint Vincent Medical Center, Portland, Oregon, 97225
    • Providence Portland Medical Center, Portland, Oregon, 97213
    • Western Oncology Research Consortium, Portland, Oregon, 97213
    • Legacy Good Samaritan Hospital and Medical Center, Portland, Oregon, 97210
  • Colorado

    • Rocky Mountain Cancer Centers-Littleton, Littleton, Colorado, 80120
    • Rocky Mountain Cancer Centers-Aurora, Aurora, Colorado, 80012
    • University of Colorado Cancer Center - Anschutz Cancer Pavilion, Aurora, Colorado, 80045
  • Washington

    • PeaceHealth Southwest Medical Center, Vancouver, Washington, 98664
    • Tri-Cities Cancer Center, Kennewick, Washington, 99336
    • Wenatchee Valley Medical Center, Wenatchee, Washington, 98801
    • Northwest CCOP, Tacoma, Washington, 98405
    • Cancer Care Northwest - Spokane South, Spokane, Washington, 99202
    • University of Washington Medical Center, Seattle, Washington, 98195
    • Cancer Care Northwest-North Spokane, Spokane, Washington, 99218
    • Harrison Medical Center, Bremerton, Washington, 98310
    • Skagit Valley Hospital, Mount Vernon, Washington, 98274
  • South Dakota

    • Rapid City Regional Hospital, Rapid City, South Dakota, 57701
  • Texas

    • Texas Oncology-Wichita Falls Texoma Cancer Center, Wichita Falls, Texas, 76310
    • Texas Oncology-Seton Williamson, Round Rock, Texas, 78665
    • University of Texas Health Science Center at San Antonio, San Antonio, Texas, 78229
    • Cancer Care Centers of South Texas- Northeast, San Antonio, Texas, 78217
    • The Klabzuba Cancer Center, Fort Worth, Texas, 76104
    • Texas Oncology-Denton South, Denton, Texas, 76210
    • Texas Oncology PA - Bedford, Bedford, Texas, 76022
    • Texas Oncology - Round Rock Cancer Center, Round Rock, Texas, 78681
    • Texas Oncology - Central Austin Cancer Center, Austin, Texas, 78731
    • Texas Oncology - South Austin Cancer Center, Austin, Texas, 78745
    • Texas Oncology-Austin Midtown, Austin, Texas, 78705
    • University of Texas Southwestern Medical Center, Dallas, Texas, 75390
    • Texas Cancer Center-Sherman, Sherman, Texas, 75090
    • Texas Oncology Cancer Center Sugar Land, Sugar Land, Texas, 77479
    • Memorial Hermann Memorial City Medical Center, Houston, Texas, 77024
    • M D Anderson Cancer Center, Houston, Texas, 77030
    • Ben Taub General Hospital, Houston, Texas, 77030
  • Oklahoma

    • University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, 73104
  • Nebraska

    • Saint Elizabeth Regional Medical Center, Lincoln, Nebraska, 68510
    • The Nebraska Medical Center, Omaha, Nebraska, 68198
    • Nebraska Methodist Hospital, Omaha, Nebraska, 68114
  • Kansas

    • University of Kansas Medical Center, Kansas City, Kansas, 66160
  • Missouri

    • Kansas City Cancer Centers - North, Kansas City, Missouri, 64154
    • Kansas City Cancer Center-Lee's Summit, Lee's Summit, Missouri, 64064
    • CoxHealth South Hospital, Springfield, Missouri, 65807
    • Mercy Hospital Springfield, Springfield, Missouri, 65804
    • University of Missouri - Ellis Fischel, Columbia, Missouri, 65212
    • Siteman Cancer Center - Saint Peters, Saint Peters, Missouri, 63376
    • Barnes-Jewish West County Hospital, Saint Louis, Missouri, 63141
    • Saint John's Mercy Medical Center, Saint Louis, Missouri, 63141
    • Siteman Cancer Center-South County, Saint Louis, Missouri, 63129
    • Washington University School of Medicine, Saint Louis, Missouri, 63110
    • Saint Louis University Hospital, Saint Louis, Missouri, 63110
    • Cape Radiation Oncology, Cape Girardeau, Missouri, 63703
  • Minnesota

    • Mercy Hospital, Coon Rapids, Minnesota, 55433
    • Unity Hospital, Fridley, Minnesota, 55432
    • Regions Hospital, Saint Paul, Minnesota, 55101
    • Minnesota Oncology Hematology PA-Maplewood, Maplewood, Minnesota, 55109
    • Mayo Clinic, Rochester, Minnesota, 55905
    • Saint Luke's Hospital of Duluth, Duluth, Minnesota, 55805
  • Iowa

    • University of Iowa Hospitals and Clinics, Iowa City, Iowa, 52242
  • Wisconsin

    • Gundersen Lutheran, La Crosse, Wisconsin, 54601
    • University of Wisconsin Hospital and Clinics, Madison, Wisconsin, 53792
    • Aspirus Regional Cancer Center, Wausau, Wisconsin, 54401
    • Langlade Hospital and Cancer Center, Antigo, Wisconsin, 54409
    • Froedtert and the Medical College of Wisconsin, Milwaukee, Wisconsin, 53226
    • Saint Vincent Hospital, Green Bay, Wisconsin, 54301
    • Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin, 53295
    • Bay Area Medical Center, Marinette, Wisconsin, 54143
  • Illinois

    • Saint John's Hospital, Springfield, Illinois, 62702
    • Loyola University Medical Center, Maywood, Illinois, 60153
    • Hines Veterans Administration Hospital, Hines, Illinois, 60141
    • Ingalls Memorial Hospital, Harvey, Illinois, 60426
    • University of Illinois, Chicago, Illinois, 60612
    • NorthShore University HealthSystem-Evanston Hospital, Evanston, Illinois, 60201
  • Mississippi

    • University of Mississippi Medical Center, Jackson, Mississippi, 39216
  • Louisiana

    • Touro Infirmary, New Orleans, Louisiana, 70115
    • Tulane University Health Sciences Center, New Orleans, Louisiana, 70112
  • Tennessee

    • Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, 37232
  • Alabama

    • University of Alabama at Birmingham, Birmingham, Alabama, 35294
  • Indiana

    • IU Health Methodist Hospital, Indianapolis, Indiana, 46202
    • Community Regional Cancer Care-East Radiation Oncology, Indianapolis, Indiana, 46219
    • Community Regional Cancer Care-North, Indianapolis, Indiana, 46256
    • IU Health Goshen Center for Cancer Care, Goshen, Indiana, 46526
    • IU Health Ball Memorial Hospital, Muncie, Indiana, 47303
    • Radiation Oncology Associates PC, Fort Wayne, Indiana, 46804
    • Parkview Hospital Randallia, Fort Wayne, Indiana, 46805
  • Kentucky

    • The James Graham Brown Cancer Center at University of Louisville, Louisville, Kentucky, 40202
    • University of Kentucky, Lexington, Kentucky, 40536
  • Ohio

    • University of Cincinnati, Cincinnati, Ohio, 45267
    • University Pointe, West Chester, Ohio, 45069
  • Georgia

    • Emory University/Winship Cancer Institute, Atlanta, Georgia, 30322
    • Atlanta VA Medical Center, Decatur, Georgia, 30033
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